Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Friendship Rehab And Health during CMS and state inspections, most recent first.
A resident with a history of TBI, anxiety, and mild neurocognitive disorder became agitated after staff moved a wheelchair he had positioned to avoid blocking his window view, leading to escalating verbal aggression toward staff. Witnesses reported that when the resident approached the nurses’ station with clenched fists and swung at an RN, the RN grabbed the resident’s arm and/or shoulder and took him to the floor, then restrained him there until supervisors arrived. Immediately afterward, the resident complained of severe left hip pain, with clinical signs of injury, and hospital evaluation confirmed a left comminuted displaced intertrochanteric fracture requiring surgical repair. Multiple staff later stated that they are not allowed to restrain residents and would instead use de-escalation, walk away, or call for assistance when residents are aggressive, while the DON acknowledged that the facility failed to protect the resident from physical abuse that resulted in actual harm.
The facility failed to timely complete and document the results of an abuse investigation after a resident with TBI, anxiety, and mild neurocognitive disorder became increasingly agitated, allegedly attacked staff, and was subsequently taken to the floor by a nurse, resulting in severe left hip pain with leg shortening and external rotation and transfer to the ED. Although an event report was submitted to the State Agency, the investigation report produced later lacked the required PB-22 and did not include the outcome of the investigation, and the DON confirmed the investigation remained incomplete beyond the required timeframe.
A resident with TBI, anxiety, and mild neurocognitive disorder had a care plan that identified refusal of care, inappropriate voiding, and physical aggression as behavior problems, but the plan lacked specific interventions for managing episodes of physical aggression. Staff, including RNs and LPNs, stated they rely on the care plan and orders for guidance when a resident is physically aggressive, yet review of the record showed only general behavioral interventions and no targeted strategies for aggression. The DON confirmed that the care plan did not contain interventions for physical aggression, resulting in a failure to provide person-centered care consistent with facility policy and state nursing service requirements.
Food items were found improperly stored in the Main Kitchen and a unit kitchenette, including an opened package of sliced turkey with no label or date and multiple unlabeled, undated items such as mayonnaise, yogurt, creamer, pizza, hot wings, and cereal. A Dietary Aide was also observed handling dirty and clean dishes in the dish room without washing hands, and the second floor kitchenette had unsanitary conditions, including an ice scoop stored in the machine, creating the potential for cross contamination.
Failure to Communicate Transfer Information and Notify Ombudsman: The facility did not document that required transfer information was sent to the receiving provider for four residents who were sent to the hospital and expected to return, including care plan goals, AD info, and representative details. For one resident with multiple serious diagnoses, the record also lacked evidence that the bed-hold policy was provided at transfer. In addition, the facility did not document written notification to the State LTC Ombudsman for seven hospital transfers.
Incomplete and Non-Individualized Care Plans: The DON confirmed that care plans for several residents did not fully address ordered care needs. A resident with diagnoses including HF and DM had a Hoyer lift transfer order, but the care plan did not specify the Hoyer pad type or size. Another resident with HTN, depression, and Alzheimer’s disease had a Hoyer lift/no ambulation order, but the care plan did not identify the lift use, pad type, or size. A resident with CVA, HF, and dysphagia had orders for Hoyer transfers, tube feeding, a G-tube, and a trach, but the care plan lacked key individualized details. A resident with frostbite wounds had a pain care plan that lacked person-centered interventions, measurable objectives, timeframes, goals, desired outcomes, and other required elements.
A resident with dementia and other diagnoses slid out of a Hoyer lift during a transfer from a wheelchair to bed, was found on her head, and was sent to the hospital for evaluation. The aides reported the sling seemed intact, but the DON stated they used the wrong type of Hoyer pad. For two other residents, Hoyer transfer orders and care plans did not specify the correct sling type or size, and staff said they chose pads by eyeballing the fit because there was no process to identify the proper sling.
Failure to Monitor Weights and Individualize Nutrition Care Plans: The facility failed to obtain required weights for several residents and did not individualize nutrition care plans for residents with specific diet and TF orders. Residents had diagnoses including HTN, CKD/ESRD, stroke, dysphagia, dementia, and hyperkalemia, with orders for consistent carb diets, renal diets, nectar liquids, and tube feeding regimens, but the care plans only listed general nutrition/hydration interventions. The DON confirmed the missing weight monitoring and lack of resident-specific nutrition care plan details.
Bedrail use lacked required assessments and accurate care planning. The facility had bilateral side rails or enabler bars in use for multiple residents with conditions including diabetes, dementia, schizophrenia, stroke, hemiparesis, epilepsy, and anoxic brain injury, but records did not consistently show the required ongoing assessments, and one resident had enabler bars without an order or safety assessment. An LPN and the ADON confirmed that assessments and care plans were incomplete or missing for several residents with bedrail use.
Failure to Complete and Review Monthly MRRs: The facility did not ensure monthly pharmacist MRRs were completed for five residents, including residents with diagnoses such as dementia, schizophrenia, depression, and psychotropic medication use. Staff confirmed missing MRR documentation in several records. For another resident, the pharmacist recommended re-evaluation of PRN lorazepam, but the attending physician’s monthly response was not documented in the record.
Improper medication storage was observed in multiple medication rooms and on a medication cart. An opened tuberculin solution, an opened Fluphenazine Deconate bottle without a date, expired influenza vaccine, and an unlabeled ice pack were found in medication room refrigerators, along with non-medication items such as snacks, perfume, and instant noodles stored in medication areas. An opened Lantus insulin pen was also found without a date, and the medication cart was left unattended and unlocked.
The facility failed to properly contain and dispose of garbage in two outdoor dumpsters. Facility policy required outside dumpsters to be kept closed and free of litter, but during an observation and interview, the Dietary Manager confirmed that the lids/covers were not closed on dumpster one and dumpster two.
Cross contamination occurred during wound care for a resident with dementia, diabetes, and a left buttocks wound when an RN failed to remove gloves and perform hand hygiene before applying clean treatment. During a medication pass, an LPN handled Depakote sprinkles with bare hands and opened the capsules without hand hygiene or gloves. In addition, enhanced barrier precautions were not followed for three residents: a NA did not wear a gown during Foley catheter care, and two rooms lacked the required EBP signage near the entrance.
Failure to Maintain Resident Dignity: Two residents were observed in situations that did not maintain dignity. One resident with a foley catheter had the collection bag hanging in view of the room entrance without a privacy cover, and an aide confirmed the issue. Another resident who required staff feeding was sitting in the dining room with a meal tray waiting to be fed while another resident ate across from them, and an LPN confirmed the dining experience was not dignified.
A resident’s private health information was posted on a sign above the bed, stating nectar thick liquids and no thin liquids. The clinical record did not show approval from the resident or representative for posting this information. The DON confirmed the facility failed to maintain confidentiality of the resident’s personal and medical records.
MDS coding did not match resident records for two residents. One resident’s MDS incorrectly indicated antibiotic use despite no supporting documentation in the chart, and another resident’s MDS coded wandering even though orders, progress notes, and an elopement risk assessment did not support that finding. The URD confirmed the inaccurate coding.
Failure to coordinate PASARR-required specialized services for a resident with bipolar disorder, anxiety, and depression. The resident had a positive PASARR Level I screen and a Level II determination requiring the facility to provide or arrange mental health services, but the PASARR recommendations were not incorporated into the resident’s assessment, care plan, or transitions of care. The SSD confirmed the resident remained a target resident and that the facility failed to coordinate the required specialized services.
A resident with DM, HTN, and schizophrenia had physician orders for routine blood glucose checks and PRN treatment for hypoglycemia, but the orders did not include any measures for hyperglycemia. An LPN confirmed the omission and stated the resident was checked twice daily and the orders only addressed low blood sugar.
Pressure Ulcer Prevention and Care Deficiency: A resident at risk for PU/PI had a physician order for bilateral offloading boots to be worn in bed, but was observed in bed without the boots on, and the resident stated staff only put them on once in a while. An LPN confirmed the boots were not applied, and the care plan lacked measurable goals and interventions related to the boots; the ADON confirmed the plan of care was not developed timely.
A facility failed to ensure two residents with limited mobility received ordered supports and had resident-specific care plans addressing their mobility needs. One resident with aphasia, epilepsy, and anoxic brain injury was observed without ordered bilateral palm guards or rolled washcloths, and the care plan did not include those interventions. Another resident with hemiparesis and chronic pain was observed without an ordered resting hand splint, and the care plan did not address left-sided weakness or splint use.
Dirty oxygen equipment and outdated humidifier bottle: Two residents receiving O2 therapy had concentrator external filters covered with copious amounts of gray fluffy substance, and one resident’s humidifier bottle was dated well beyond the expected change interval. One resident had COPD, sudden respiratory failure, renal failure, and pancytopenia with an order for PRN O2 at 2 LPM via NC, while the other had COPD, heart disease, long-term respiratory failure, and seizures with a care plan for O2 therapy as needed. RN and DON interviews confirmed the filters were dirty and the humidifier bottle should have been removed.
Incomplete dialysis communication for a resident with ESRD and HTN was identified when the facility’s records lacked complete dialysis communication forms on multiple occasions. The resident had an order for dialysis transport three times weekly, but the chart did not include complete forms for several dialysis days, and an RN confirmed the missing documentation and inconsistent communication with the dialysis center.
Failure to Provide Trauma-Informed Care for Resident with PTSD: A resident with PTSD, depression, and anxiety had a care plan that listed only general mood concerns and did not identify PTSD, triggers, or ways to avoid re-traumatization. RN confirmed the care plan lacked trauma-informed interventions, and the report stated the facility failed to ensure trauma-informed care for the resident.
Mechanical Lift Competency Deficiency: Two NAs lacked documented competency for Hoyer lift use and proper sling selection. A resident with dementia, depression, and HTN was ordered to be transferred with a Hoyer lift and assist of two, but during a wheelchair-to-bed transfer the resident slid out of the lift and landed on her head. The DON stated the aides used a Hoyer pad with the legs cut out, and the facility’s competency checklist did not address how to determine the proper sling type and size.
Failure to ensure residents understood a binding arbitration agreement: two residents with cognitive impairment were involved, including one with Crohn's disease, PVD, and intellectual disabilities and another with dementia, depression, and anxiety. MDS findings showed BIMS scores of 10 and 0, yet one resident signed the agreement and the other verbally agreed despite severe impairment, and the admission director confirmed the agreement was not explained in a way the resident and representative could understand.
Missing Hospice Documentation: The facility failed to maintain current hospice records for two residents receiving hospice services. One resident’s binder lacked a current hospice POC and updated med list, and another resident’s binder did not include a current POC. An LPN, RN, and DON confirmed the missing documentation during interview; one resident had diagnoses including HTN, depression, and Alzheimer’s disease, and the other had HTN, anxiety, and depression.
Expired Inspection Sticker on Resident Transport Vehicle: A resident reported that one of the facility vehicles used for resident transport had an expired inspection sticker. Surveyors observed vehicle number one in the parking lot with an expired inspection sticker, and van drivers confirmed the vehicle's inspection had expired. The NHA confirmed the facility failed to ensure the equipment was in safe operating condition.
Failure to provide required annual nurse aide in-service training. The facility did not ensure one NA received the minimum 12 hours of yearly in-service education required by policy. Records showed the NA did not complete the required training hours, and the Education Dept RN confirmed the deficiency during interview.
A facility failed to post required resident-facing information in accessible areas. Surveyors found no contact information for APS, incomplete State Agency and Ombudsman details, no Medicaid Fraud Unit address or email, and no statement that residents may file a complaint with the State Survey Agency; the NHA confirmed the missing postings.
A facility failed to provide grievance official information throughout the building as required. During a tour, grievance boxes were observed without the grievance official’s name, address, email, or phone number, and the NHA confirmed the information was not accessible to all residents.
Multiple residents reported that the food served at lunch was unappetizing, cold, and lacked flavor, with direct observation confirming that the turkey pot pie was served in a soup-like form and missing key ingredients. The Food Service Director acknowledged the poor quality of the meal, citing issues with a new food vendor and inconsistent cooking staff.
A resident with cognitive impairment and a history of exit-seeking behavior was able to leave the facility unsupervised after learning the elevator code, despite being on a secure unit with a wander guard and scheduled 15-minute checks. Staff failed to consistently document required safety checks, and the resident was not accounted for during routine rounds. The resident was later found by police outside the facility, and staff interviews confirmed lapses in supervision and security protocols.
The NHA and DON did not ensure proper supervision for a resident at high risk for elopement, resulting in the resident leaving the facility and creating an immediate jeopardy situation. This failure was identified through review of job descriptions, facility and clinical records, and staff interviews, and demonstrated noncompliance with professional standards and facility policies.
The facility failed to pay significant outstanding balances to a staffing agency, water vendor, and sewage vendor, resulting in service suspension and legal action by vendors. The Nursing Home Administrator confirmed the facility was not current on payments and was seeking payment plans.
For nine days, the facility did not have a qualified social worker on staff for approximately 388 residents. The new hire's credentials did not meet the required qualifications, and the previous social worker was not present during this period, resulting in a lapse in compliance with social services staffing requirements.
The facility failed to correct previously cited deficiencies regarding non-payment to essential water and sewage vendors, despite QAPI policies and corrective plans. Significant overdue balances remained, with vendors confirming ongoing payment delays and legal action initiated. The NHA acknowledged the QAPI program did not resolve these issues, potentially affecting all residents.
The facility did not ensure that two residents with cognitive impairment or legal guardianship had the capacity or proper authorization to sign admission agreements, and failed to provide three residents or their representatives with a choice regarding transfer to other facilities. These actions were confirmed through record reviews and interviews, showing a lack of informed consent and resident choice in critical processes.
The facility did not properly notify resident representatives about transfers, as required by policy and regulation. In several cases, representatives only learned of the transfers from the residents themselves or from the receiving facility, despite documentation indicating families were aware. Residents affected had a range of cognitive and mental health conditions, and interviews confirmed a consistent lack of direct communication from the facility.
The facility did not ensure that necessary resident information, such as care plan goals and advanced directives, was communicated to receiving health care providers during transfers, nor did it document the reasons for transferring several residents with complex medical and psychiatric conditions. This deficiency was confirmed by the DON and identified through policy review, clinical record review, and staff interviews.
Two residents were unable to use their in-room bathroom for about a month due to it being inoperable and marked with caution tape. Staff confirmed that these residents had to use a restroom on another unit, and maintenance had not addressed the issue recently. The DON acknowledged that no room move or alternative accommodation was offered.
A resident with multiple chronic conditions was given a double dose of morning medications after an LPN, unable to document the administration in the electronic medical record and unaware that the medications had already been given, provided them again at the resident's request. The resident experienced mild shortness of breath and hypotension, leading to a transfer to the ER. The DON confirmed the failure to prevent significant medication errors.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any individual.
A resident was subjected to physical restraints without a documented medical need, in violation of requirements that ensure restraints are only used for medical treatment.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The lack of proper safety measures and oversight increased the risk of preventable incidents for residents.
The facility did not maintain cleanliness and sanitation in the main kitchen and basement storage areas, with observations of standing water, debris, and improperly stored or undated food items. Food storage areas had water leaks, crumbling ceilings, and unlabeled or expired food, all confirmed by management as not meeting required standards.
The facility did not pay significant outstanding bills to two vendors for essential services, with no payment plans in place and vendors considering service interruption. The NHA confirmed the unpaid balances and lack of timely payment, indicating non-compliance with state regulations regarding financial management and resident safety.
The facility did not provide appropriate body soap for resident care, instead instructing staff to use hand soap from sink dispensers. Multiple staff reported bringing in their own soap due to concerns about residents' skin and the unsuitability of hand soap for bathing. Several residents with complex medical needs were affected by this deficiency.
Surveyors found that the facility did not provide a safe, clean, or homelike environment in all resident areas, with issues such as obstructed exits, damaged flooring, peeling walls, exposed metal, dirty bathrooms, and inadequate heating or cooling. Staff and management confirmed these deficiencies, and a resident reported problems with room temperature and water leakage due to broken fixtures.
The facility did not provide required QAPI training to five staff members, including nurse aides, an LPN, and an RN, as confirmed by review of education files and staff interviews. This deficiency was identified through examination of facility assessment documents and was confirmed by the HR Director.
The facility did not provide adequate privacy in restroom facilities on two floors, as several bathroom stalls were missing curtains or had improperly sized curtains. This lack of privacy was confirmed by staff, including an RN, an LPN, and the DON.
Failure to Protect Resident From Physical Abuse Resulting in Hip Fracture
Penalty
Summary
The facility failed to protect a resident from physical abuse when a registered nurse (RN) took the resident to the floor during an altercation, resulting in a left comminuted displaced intertrochanteric hip fracture that required surgery. Facility policy on "Abuse: Protection From" stated that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property, and that residents must not be subjected to abuse by anyone, including staff. The resident involved had a history of traumatic brain injury, anxiety, and mild neurocognitive disorder with behavioral disturbance, but was assessed as cognitively intact with a BIMS score of 13. On the evening of the incident, the resident became agitated after staff moved a wheelchair that he had positioned to avoid blocking his window view, and he began yelling and cursing at a nurse aide (NA) about the wheelchair placement. According to multiple staff statements and nursing documentation, the resident paced in his room, continued yelling, and then left the room to go to the bathroom. After several minutes, he approached the nursing station, yelling and threatening the RN, with witnesses reporting that he had his fists clenched and was swinging at the nurse. The RN reported that when the resident swung at him, he grabbed the resident’s arm and/or shoulder and took him down or assisted him to the floor, then restrained him there until supervisors arrived. Witnesses, including NAs and another RN, consistently described the nurse catching the resident’s swing by the forearm or grabbing his shoulder/arm and putting or sitting him down on the floor, after which the resident was observed lying on his right side in front of the elevator, screaming in pain and holding his left hip. Following the takedown, staff observed that the resident complained of 10/10 left hip pain, with the left leg shortened and externally rotated. The resident told staff and later hospital providers that the nurse had “tackled” him to the floor. Hospital records documented that the resident reported being tackled after an altercation about moving a wheelchair to see the sunset, and confirmed a left comminuted displaced intertrochanteric fracture requiring orthopedic surgical intervention. In subsequent staff interviews, multiple nurses and NAs stated that facility practice when a resident exhibits aggressive behavior is to walk away, call for help or a supervisor, attempt de-escalation, remove triggers, and that they are not allowed to restrain residents or hold them to the ground. The Director of Nursing acknowledged that the facility failed to protect the resident from physical abuse that resulted in actual harm in the form of the hip fracture. The deficiency was cited under multiple Pennsylvania regulatory provisions, including 28 Pa. Code 201.14(a) Responsibility of Licensee, 201.18(b)(1)(3) Management, 201.29(a)(c)(d)(j) Resident Rights, 211.10(c)(d) Resident Care Policies, and 211.12(d)(1)(3) Nursing services. These citations reflect that the resident’s right to be free from abuse and the facility’s obligations regarding resident care policies and nursing services were not upheld in this incident, as evidenced by the RN’s physical handling of the resident that led to a serious injury.
Failure to Timely Complete Abuse Investigation After Staff–Resident Altercation With Serious Injury
Penalty
Summary
The deficiency involves the facility’s failure to timely complete and report an investigative report for an allegation of physical abuse resulting in serious bodily injury. Facility policy on Reporting Unusual Occurrences requires that suspected, alleged, or actual abuse, neglect, misappropriation of resident property, fractures, incidents requiring transfer for medical evaluation, and staff-to-resident altercations be reported to appropriate agencies, with a written report forwarded within five working days. Federal regulation at 42 CFR §483.12(c)(4) similarly requires that, at the conclusion of the investigation and no later than five working days of the incident, the facility must report the results of the investigation. The facility’s Abuse policy states that each resident has the right to be free from abuse, including infliction of injury with resulting physical harm, pain, or mental anguish. Clinical record review showed that the resident had diagnoses including traumatic brain injury, anxiety, and mild neurocognitive disorder with behavioral disturbance. A nursing progress note documented that supervisors were urgently called to a unit for a resident attacking staff; upon arrival, the resident was found lying on his right side, screaming, and complaining of left hip pain. The resident stated that a staff member had “tackled” him and that he had intended to “knock his ass out.” Witness accounts indicated the resident had increasing agitation and attempted to punch the nurse and nurse aides; the nurse reported that when the resident swung at him, he grabbed the resident’s arm/shoulder and took him down to the floor. The resident had 10/10 left hip pain with left leg shortening and external rotation, and the physician ordered transfer to a local emergency room. An event report was submitted to the State Agency the following morning, but the facility’s investigation report produced a week later did not include a PB-22 or the outcome of the investigation. In an interview, the DON confirmed the investigation was not complete and acknowledged the facility failed to timely complete the investigative report for this allegation of physical abuse with serious bodily injury.
Failure to Include Interventions for Physical Aggression in Behavior Care Plan
Penalty
Summary
The facility failed to develop a complete, person-centered care plan with measurable interventions for a resident with documented behavioral issues, including physical aggression. Facility policy required an individualized, interdisciplinary care plan for each resident, initiated on admission and updated with each significant event, to address actual and potential issues, manage risk factors, and promote the resident's highest practicable level of functioning. The resident in question had diagnoses of traumatic brain injury (TBI), anxiety, and mild neurocognitive disorder with behavioral disturbance. The current care plan identified a behavior problem of refusal of care and aggression, including voiding in inappropriate areas, refusal to bathe or change clothes or linens, disturbing other residents' televisions and remotes, and physical aggression. The stated goal was for the resident to have fewer episodes of refusal of care and no aggression by the review date, with general interventions such as anticipating and meeting needs, encouraging appropriate expression of feelings, providing emotional support, and obtaining psychology consults as needed. Despite listing physical aggression as a behavior problem, the care plan did not include any specific interventions or instructions for staff to use when the resident was experiencing physical aggression. Multiple nursing staff, including RNs and LPNs, reported in interviews that they would look to the care plan, physician orders, or behavioral care plans for guidance on how to respond to a resident exhibiting physical aggression, indicating their expectation that such interventions should be present in the care plan. Upon review of the resident's care plan during the survey, an RN acknowledged that interventions for physical aggression were missing. The Director of Nursing also confirmed that the resident's current care plan lacked interventions for physical aggression and that the facility failed to develop a care plan that included instructions to provide person-centered care for this resident, in violation of applicable state regulations regarding resident care policies and nursing services.
Food Storage, Hand Hygiene, and Kitchenette Sanitation Deficiencies
Penalty
Summary
The facility failed to properly store, label, and date food items in the Main Kitchen and second floor kitchenette. During an observation in walk-in refrigerator Number One, an opened package of sliced turkey was found unsealed with no label or date, and the Dietary Manager confirmed the condition of the item. In the second floor kitchenette, multiple food items were observed without labels or dates, including mayonnaise, two nonfat peach yogurts, Starbucks creamer, an individual pizza, frozen hot wings, and two crispy rice cereals. The ice machine also had its scoop stored inside the machine rather than in a separate scoop holder. The facility also failed to properly perform handwashing in the Dish Room. A Dietary Aide was observed loading dirty dishes into the dish machine and then removing clean dishes without washing her hands. The Dietary Manager confirmed that handwashing was not properly performed. In addition, the second floor kitchenette was observed with unsanitary conditions that created the potential for cross contamination, and a Registered Nurse confirmed the condition of one of six unit kitchenettes.
Failure to Communicate Transfer Information and Notify Ombudsman
Penalty
Summary
The facility failed to ensure that required resident information was communicated to the receiving health care provider for four of seven sampled residents who were transferred to the hospital and expected to return. For Residents R9, R55, R79, and R178, the record lacked documented evidence that transfer information such as care plan goals, advanced directive instructions, resident representative information, special instructions for ongoing care, and other information needed to meet the resident’s specific needs was sent to the receiving facility. The facility policy reviewed stated that a clinical summary and specified transfer information must be communicated and documented in the medical record when a resident is transferred. Resident R9 had diagnoses including an open wound of the scrotum and testes, muscular dystrophy, paraplegia, and neuromuscular dysfunction of the bladder. Progress notes showed R9 was transferred to the acute care hospital on two occasions, and the record lacked evidence that the facility communicated the required transfer information to the receiving provider for those transfers. The record also lacked evidence that the facility made the bed-hold policy available to R9 or the resident’s representative at the time of transfer. The facility also failed to notify the Office of the State Long-Term Care Ombudsman for seven of seven hospital transfers involving Residents R9, R10, R55, R79, R178, R273, and R300. The records for these residents showed hospital transfers for evaluation or treatment, but there was no documented evidence that written transfer notification was provided to the Ombudsman. Staff interviews confirmed there was no evidence of the bed-hold policy for R9 and no evidence that the State Ombudsman office was notified for the listed residents’ transfers.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to develop comprehensive, individualized care plans to meet resident care needs for four of 50 residents. Facility policy required interdisciplinary care plans that address residents’ needs as identified through assessment, include measurable objectives and timetables, respect the right to decline treatment, and use an interdisciplinary approach. Survey review found that the care plans for Residents R2, R55, R273, and R280 did not fully reflect the residents’ assessed needs and ordered treatments. Resident R2 had diagnoses including high blood pressure, heart failure, and diabetes, and physician orders required transfer with a Hoyer lift and assist of two. Although the care plan addressed Hoyer lift transfers, it did not identify the kind of Hoyer pad or the Hoyer size to use. Resident R55 had diagnoses including high blood pressure, depression, and Alzheimer’s disease, and orders required transfer with a Hoyer lift, assist of two, with no ambulation. The care plan stated to assist with transfers and ambulation as ordered, but did not identify the use of the Hoyer lift, the kind of Hoyer pad, or the Hoyer size to use. Resident R273 had diagnoses including cerebral infarction, heart failure, and dysphagia, with orders for Hoyer lift transfers, no ambulation, Jevity 1.5 tube feeding at 65 ml/hour with 60 ml water flush every hour for 24 hours, a 20 French G-tube, and a 60 xlt Shiley trach. The care plan failed to be individualized and person-centered and did not identify the kind of Hoyer pad, correct Hoyer pad size, type of tube feeding, G-tube size, or trach tube size. Resident R280 had frostbite with necrosis of the left foot and right toes, morbid obesity, and psychoactive substance abuse in remission; the pain care plan included monitoring for non-verbal pain and administering ordered pain medications, but it did not include individualized person-centered pharmacological and non-pharmacological interventions, measurable objectives, timeframes, goals and desired outcomes, services to attain or maintain highest practicable well-being, specialized services, referral to the local contact agency, or services not provided due to refusal of treatment.
Unsafe Hoyer Lift Transfers and Lack of Resident-Specific Sling Guidance
Penalty
Summary
The facility failed to ensure that a resident was free from a preventable accident during a Hoyer lift transfer. Resident R55 had diagnoses including high blood pressure, depression, and Alzheimer's disease, and physician orders required transfer with a Hoyer lift, assist of two, with no ambulation. During a transfer from wheelchair to bed, two nurse aides were using the Hoyer lift when the resident slid out of the lift and landed on her head. Nursing was notified immediately, the resident was assessed, and she was sent to the hospital for evaluation; the witness statement noted that no injuries occurred. Facility interviews showed that the nurse aides believed the Hoyer pad and lift were functioning properly, but one aide stated the resident began to slide and they tried to hurry the transfer before she fell out. Another aide stated the resident slid out bottom first and that the Hoyer pad remained attached to the lift after the fall. The DON stated the aides used a Hoyer pad with the legs cut out rather than the one-piece square pad, and the facility reviewed the scenario but could not determine what went wrong. The facility also failed to ensure that residents were free from potential accidents during Hoyer transfers for two other residents, R2 and R273. Both residents had physician orders and care plans for Hoyer lift transfers with assist of two, but neither the orders nor the care plans specified what kind or size of Hoyer pad to use based on the resident's weight and height. Staff interviews showed that aides selected pads by eyeballing or gauging the size, and one aide stated there was no process to determine which pad or size went with a resident. The DON confirmed the facility did not have a process to determine the correct Hoyer pad or size.
Failure to Monitor Weights and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for four residents by not obtaining required weights for Resident R7, Resident R82, Resident R87, and Resident R108. The facility policy stated residents are to be weighed within 24 hours of admission, then weekly for four weeks, and monthly unless otherwise noted. Resident R7’s weight record did not show documented weights for June 2025, July 2025, September 2025, and December 2025. Resident R82’s last recorded weight was 169.8 pounds on 12/1/25, and no monthly weight was obtained in January or February 2026. Resident R87 was not weighed in January 2026. Resident R108 had no documented weights for December 2025 and January 2026, and the record did not show weights on 2/18/26 or 2/25/26 despite an order for weekly weights x 4 weeks. The facility also failed to individualize care plans to address resident-specific nutritional concerns for Resident R3, Resident R4, Resident R79, Resident R82, and Resident R87. Resident R3 had diagnoses including high blood pressure, hyperkalemia, and chronic pain, and a physician order for a consistent carbohydrate mechanical soft diet with nectar liquids; however, the care plan only listed general nutrition/hydration interventions and did not include the ordered diet specifics. Resident R4 had diagnoses including high blood pressure, chronic pain, and kidney failure, with an order for a consistent carbohydrate diet, regular texture, thin liquids, and a renal control shake daily, but the care plan again contained only general interventions and no resident-specific diet details. Resident R79 had diagnoses including high blood pressure, ESRD, and anxiety, and a physician order for a renal diet with potassium, protein, and sodium restrictions and no seeds, nuts, or hulls. The care plan listed nutrition/hydration risk and included a 1500 mL fluid restriction, but the active physician orders did not include a fluid restriction, and the care plan did not reflect the ordered diet specifics. Resident R82 had a physician order for Jevity 1.2 tube feeding at 70 mL per hour with 35 mL water flush every hour, and Resident R87 had an order for Osmolite 1.2 tube feeding at 55 mL per hour with 35 mL water flush every hour; both care plans only included general tube feeding interventions without resident-specific diet details. The DON confirmed the facility failed to monitor weights for the affected residents and failed to individualize care plans for the residents with nutritional concerns.
Bedrail use lacked required assessments and accurate care planning
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments for bedrail use for seven residents who had bilateral side rails or enabler bars on their beds. The facility policy stated that enabler bars or side rails are prohibited unless criteria for use are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Review of the clinical record and observations showed that Residents R5, R6, R17, R87, R108, R124, and R190 had bedrails or enabler bars in use, but the required assessments were not consistently completed or documented. Resident R5 had diagnoses including diabetes, hyperlipidemia, and anxiety, and physician orders for bilateral bed enablers to aid in independence with bed positioning. During observation, bilateral side rails were present, but the record showed enabler bar assessments only on 2/9/26 and 3/11/26, with no prior assessments completed. Resident R6 had diagnoses including high blood pressure, diabetes, schizophrenia, and absence of the left leg below the knee, and had an order for bilateral bed enablers to increase independence with bed positioning. Bilateral side rails were observed on the bed, but the record showed assessments only on 1/8/23, 2/9/26, and 3/11/26. An LPN confirmed that R5 and R6 did not have bedrail assessments to ensure the rails were used to meet their needs and the risks associated with bedrail use. Resident R17 had diagnoses including high blood pressure, obstructive uropathy, and left hemiparesis, and had a physician order for bilateral bed enabler bars, but the record failed to reveal an ongoing accurate assessment for use. Resident R87 had diagnoses including high blood pressure, dysphagia, and stroke; bilateral enabler bars were observed, but there was no physician order and no assessment showing the resident was safe to use them. Resident R108 had diagnoses including dementia, bipolar disorder, and anxiety, and had an order for bilateral enabler bars, but the record failed to reveal an ongoing accurate assessment. Resident R124 had diagnoses including aphasia, epilepsy, and anoxic brain injury; bilateral padded enabler bars were observed, but there was no active physician order, no ongoing assessment, and no goals or interventions in the comprehensive care plan. Resident R190 had diagnoses including high blood pressure, hyperlipidemia, and dementia, had an order for bilateral enabler bars, and had enabler bars observed on the bed, but the record failed to reveal an ongoing accurate assessment. The ADON confirmed that the facility failed to maintain accurate care plans for R124 and failed to conduct ongoing accurate assessments for R17, R108, R124, and R190.
Failure to Complete and Review Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure monthly medication regimen reviews (MRRs) were completed by a licensed pharmacist for five residents, including residents with diagnoses such as multiple sclerosis, dementia, anxiety, anoxic brain damage, adult failure to thrive, high blood pressure, hyperkalemia, chronic pain, diabetes, schizophrenia, anxiety disorder, and depression. The facility policy stated that a licensed pharmacist would review each resident’s drug regimen at least monthly and report irregularities to the attending physician and DON. However, the clinical records for residents R3, R6, R97, R133, and R137 did not contain the required monthly pharmacist reviews for the months identified in the report, and staff acknowledged that there had been issues with the reviews. For Resident R3, the clinical progress notes did not include a pharmacy notation or review by a licensed pharmacist for August 2025 and November 2025. For Resident R6, the clinical record contained no documentation that pharmacy medication regimen reviews were completed by a licensed pharmacist, and an LPN confirmed during interview that the record lacked any MRRs and stated there had been an issue with them. For Resident R97, the record failed to provide completed MRRs for November 2025 and December 2025, and for Resident R133, the record failed to provide completed MRRs for October 2025 and November 2025. For Resident R137, the clinical record also failed to include documentation that pharmacy medication regimen reviews were completed by a licensed pharmacist. The resident’s MDS indicated use of antipsychotic, antianxiety, and antidepressant medications, and physician orders directed monitoring for side effects of psychotropic usage. In addition, for Resident R7, the pharmacist recommended discontinuation or re-evaluation of PRN lorazepam, but the clinical record did not include a response from the attending physician regarding that recommendation for the monthly review; a CRNP later addressed the MRR and continued the medication. The DON confirmed that the facility failed to ensure MRRs were completed monthly for residents R3, R6, R97, R133, and R137, and failed to ensure the MRR for Resident R7 was reviewed by the attending physician monthly.
Improper Medication Storage and Unsecured Medication Cart
Penalty
Summary
The facility failed to properly store medications in three medication rooms and one medication cart, and failed to properly secure one medication cart when not in use. In the 5 Main Medication Room, an opened bottle of tuberculin solution was observed in the refrigerator with no open date. In the 2 East medication room refrigerator, an opened bottle of Fluphenazine Deconate was found without a date, a box of Afluria influenza vaccine contained 12 syringes with an expiration date of 5/25, and a white unlabeled ice pack was in the freezer. In the 3 East medication room, the bottom cupboard contained opened packages of Oreo cookies, moon pies, iced oatmeal cookies, animal crackers, and pretzels, while the upper cupboard contained an opened perfume bottle and two cups of instant noodles. The medication room refrigerator also had a brown substance on the inside bottom and a black substance around the seal. On the 3 East unit's [NAME] Hall medication cart, one opened Lantus insulin pen was observed without a date. The same medication cart was later observed left unattended and unlocked outside of room [ROOM NUMBER]. Staff interviews confirmed each of these observations and acknowledged that the facility failed to properly store medications in the affected medication rooms and cart, and failed to properly secure the cart while it was not in use.
Improperly Closed Outdoor Dumpsters
Penalty
Summary
The facility failed to properly contain and dispose of garbage in two outside dumpsters, identified as dumpster one and dumpster two, to prevent the potential for rodent and insect infestation. Review of the facility policy, Garbage and Rubbish Disposal, dated 10/1/25, indicated that outside dumpsters provided by the garbage pick-up services must be kept closed and free of litter around the dumpster area. During an observation and interview of the facility's outdoor trash receptacles on 3/10/26 at 1:30 p.m., the Dietary Manager, Employee E19, confirmed that the lid/cover was not closed on dumpster one and dumpster two, and that the facility failed to properly contain and dispose of garbage in the outside trash receptacles.
Cross Contamination and EBP Failures During Wound Care, Medication Pass, and Resident Care
Penalty
Summary
Cross contamination occurred during a wound dressing change for Resident R293. The resident had diagnoses including dementia, diabetes, and high blood pressure, and had a physician order for daily wound care to the left buttocks using vashe, Santyl, alginate, and a dressing. During the observed dressing change, the RN cleaned the bedside table, placed a clean barrier and supplies, removed the old dressing, and cleansed the wound, but then failed to remove gloves and perform hand hygiene before applying the clean wound care treatment to the wound. Cross contamination also occurred during medication administration for Resident R248. The resident had diagnoses including high blood pressure, diabetes, and a seizure disorder, and had an order for Depakote sprinkles 125 mg, two capsules by mouth twice daily. During the medication pass, the LPN placed the capsules in a medication cup, placed pudding in another cup, then used bare hands to take the capsules from the cup, open them, and sprinkle the medication into the pudding without completing hand hygiene or using gloves. Transmission-based precautions were not implemented as ordered for Residents R18, R111, and R276. Resident R18 had an order for enhanced barrier precautions due to a Foley catheter, with gloves and gowns required for high-contact care, but the NA performing catheter care did not wear a gown and stated gowns were only used if the resident had an infectious organism in the urine. Resident R111 and Resident R276 both had orders and care plans for enhanced barrier precautions related to wounds or a urostomy, but observation showed their room doors did not have an enhanced barrier precaution sign near the entrance, and the LPN confirmed the signs were missing.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure resident dignity was maintained for two residents. Resident R17 had diagnoses including high blood pressure, obstructive uropathy, and hemiparesis, and had a physician order for a 16 French foley catheter with a 5 cc balloon. During an observation, R17's foley catheter collection bag was partially full of urine, hanging on the right side of the bed facing the room entrance, and it did not have a privacy cover applied. A nurse aide confirmed the bag had no privacy cover and that the facility failed to ensure care was provided in a manner that maintained R17's dignity. Resident R298 had diagnoses including dementia, depression, and cachexia, and had a physician order for upright or out of bed for all meals and full feed. During an observation, R298 was sitting in the 5 Main dining room at a table with a meal tray on the table next to the resident, while another resident sat across from R298 eating lunch. An LPN confirmed that R298 was a staff feed and was waiting in the dining room to be fed lunch, and also confirmed that the facility failed to provide a dignified dining experience for R298.
Failure to Keep Resident Health Information Confidential
Penalty
Summary
The facility failed to maintain the confidentiality of one resident’s personal and medical records. Facility policy titled Resident Rights, dated 10/1/25, stated that residents have the right to privacy in treatment and personal care. Review of the clinical record showed that Resident R3 was admitted on [DATE], and the MDS dated 12/8/25 listed diagnoses of high blood pressure, hyperkalemia, and chronic pain. During an observation on 3/10/26 at 9:18 a.m., a sign posted on R3’s wall above the bed stated, “Nectar thick liquids, no thin liquids.” The clinical record did not contain documentation that the resident or the resident’s representative approved posting this private health information. During an interview on 3/12/26 at 2:00 p.m., the DON confirmed that the facility failed to maintain the confidentiality of the resident’s personal and medical records.
MDS Coding Did Not Match Resident Records
Penalty
Summary
The facility failed to ensure the MDS accurately reflected resident status for two residents. For one resident, the RAI User Manual states Section N0415F, Antibiotics, should be checked if the resident received antibiotics during the last 7 days or since admission/entry or reentry if less than 7 days. The resident’s clinical record showed an admission date of 12/30/24 and diagnoses including stroke, difficulty speaking, left-sided weakness, and HIV, but the Annual MDS with ARD 1/06/26 coded Section N0415F as yes for receiving antibiotics admission/entry or reentry if less than 7 days. The clinical record did not contain evidence that the resident had received antibiotics during that time frame, and the Director of Utilization Review confirmed the coding was incorrect during interview on 3/12/26. For the second resident, the MDS dated 2/4/26 coded Section E900-Wandering as a 2, indicating the resident had wandered in the last 4-6 days. However, the resident’s physician orders dated 1/9/26 did not include a wander guard, progress notes from 1/1/26 through 2/4/26 showed no wandering behavior, and the elopement risk assessment indicated a score of 0 with no risk of elopement. During interview on 3/12/26, the Utilization Review Director confirmed the facility failed to ensure the MDS accurately reflected the resident’s status.
Failure to Coordinate PASARR-Required Specialized Services
Penalty
Summary
The facility failed to incorporate the recommendations from a PASARR Level II determination and PASRR evaluation report into the assessment, care planning, and transitions of care for one resident. The resident’s clinical record showed diagnoses of bipolar disorder, anxiety, and depression, and a PASARR Level I screening identified a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition, requiring a Level II evaluation. The PASARR Level II determination letter stated that the resident was eligible for the level of services provided by a nursing facility and that the facility must provide or arrange mental health services as needed, including systematic plans to facilitate appropriate behavior, drug therapy monitoring, structured social activities, daily living skills training, therapy, support networks, and formal behavior modification programs. During interview, the Social Services Director confirmed that the PASARR II form identified the resident as a target resident and that no more recent documentation existed to remove the resident from those requirements, and also confirmed that the facility failed to provide coordination of specialized services for the resident.
Missing Hyperglycemic Protocols in Resident Orders
Penalty
Summary
The facility failed to include hyperglycemic protocols in the physician orders for one resident with diabetes, hypertension, and schizophrenia. Review of the resident’s clinical record showed orders for Accu-checks every day and evening shift, along with orders for Glucose Gel 40% to treat hypoglycemia when blood glucose was less than or equal to 70 mg/dl and the resident was able to swallow, and Zegalogue subcutaneous solution for hypoglycemia when the resident was unresponsive or unable to swallow. The resident’s physician orders did not include any measures for hyperglycemia. During an interview, an LPN confirmed that the orders failed to include hyperglycemic measures and stated that the resident was checked twice a day and that the orders were only for hypoglycemia. The interview also confirmed that the facility failed to include hyperglycemic protocols for this resident.
Pressure Ulcer Prevention and Care Deficiency
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for Resident R108. The resident was admitted with diagnoses including dementia, bipolar disorder, and anxiety. The MDS dated 2/19/26 coded the resident as at risk for developing pressure ulcers/injuries. A physician order dated 11/13/25 directed bilateral offloading boots to be worn in bed as tolerated to decrease the risk of skin breakdown, but during an observation on 3/9/26 at 10:56 a.m., the resident was lying in bed without the boots on. The resident stated that staff would put the boots on once in a while, and an LPN confirmed during interview that the boots were not applied and that the facility failed to make certain the resident received necessary treatment and services to prevent pressure ulcers. The resident’s comprehensive care plan reviewed on 3/11/26 did not include measurable goals or interventions related to the use of bilateral offloading boots. During an interview on 3/12/26, the ADON confirmed that the facility failed to develop a plan of care timely with measurable goals and interventions related to prevention of pressure ulcer development for Resident R108. The facility policy stated that residents will receive skin care, repositioning, and nutritional support to assist in preventing pressure ulcers, and that the care plan will identify residents at risk and provide aggressive, appropriate preventative measures specific to their risk factors.
Failure to Provide Ordered Mobility Supports and Care Planning
Penalty
Summary
The facility failed to ensure two residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility, and failed to develop and revise comprehensive resident-specific care plans for those needs. Facility policy stated that each resident should have an individualized interdisciplinary care plan addressing needs identified through assessment and oriented toward preventing avoidable declines in functioning. For Resident R124, the clinical record showed diagnoses including aphasia, epilepsy, and anoxic brain injury. A physician order dated 1/6/26 directed rolled washcloths or palm guards in both hands as tolerated with daily skin checks and hand hygiene, but during observations on 3/9/26 at 10:16 a.m. and 12:09 p.m., R124 was lying in bed without bilateral palm guards or rolled washcloths in place. During interview on 3/9/26, an LPN confirmed R124 did not have the ordered hand supports applied. The comprehensive care plan for R124 addressed impaired physical mobility and potential for increased contractures, with interventions for soft external dorsiflexion braces, but it did not include measurable goals or interventions for bilateral palm guards or rolled washcloths, and the active physician orders did not include the dorsiflexion braces. For Resident R307, the record showed diagnoses of high blood pressure, hemiparesis, and chronic pain. A physician order dated 12/17/24 directed a resting hand splint to the left upper extremity before breakfast and removed at lunch, but during observation on 3/12/26 at 9:16 a.m., R307 was in bed without the splint applied. The resident stated the splint was not always applied by staff, an LPN confirmed it was not on as ordered, and the comprehensive care plan did not include interventions for left-sided weakness or use of the resting hand splint.
Dirty oxygen equipment and outdated humidifier bottle
Penalty
Summary
The facility failed to promote cleanliness and prevent the spread of infection regarding respiratory care equipment for two residents receiving oxygen therapy. A facility policy titled Oxygen Administration stated that staff were to change pre-filled humidification systems and tubing at least weekly and check concentrator filters for cleanliness and clean them as needed with soap and water. Resident R8 had diagnoses including COPD, sudden respiratory failure, renal failure, and pancytopenia, and had a physician order for supplemental oxygen at 2 LPM via nasal cannula as needed for shortness of breath. The resident’s TAR showed oxygen use on multiple dates, but observations on 3/09/26 and 3/10/26 found the oxygen concentrator external filter covered with copious amounts of gray fluffy substance, and the humidifier bottle was dated 12/09/25. Resident R98 had diagnoses including COPD, heart disease, long-term respiratory failure, and seizures, and had a care plan for oxygen therapy as needed to maintain oxygen saturation within parameters. During an observation on 3/09/26, the resident was lying in bed with the head elevated and the oxygen nasal cannula in place, while the external oxygen concentrator filter was covered with copious amounts of gray fluffy substance. During interview, RN E34 confirmed that R8’s external concentrator filter was dirty and that the humidifier bottle should have been removed when the resident needed oxygen, and also confirmed that R98’s external concentrator filter was dirty. The DON later confirmed that the external concentrator filters should be cleaned and that the humidifier bottle should have been removed.
Incomplete Dialysis Communication for a Resident with ESRD
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for Resident R79, who was admitted with diagnoses of high blood pressure, ESRD, and anxiety and had a physician order for dialysis leave at 8:30 a.m. on Monday, Wednesday, and Friday. Facility policy required residents ordered dialysis therapy to be monitored, with documentation maintained in the medical record, and required assessment before and after dialysis treatment as well as compliance with the individualized plan of care. Review of Resident R79’s clinical record showed that complete dialysis communication forms were missing for five days during the period from 2/1/26 through 3/9/26, specifically on 2/9/26, 2/16/26, 2/25/26, 2/27/26, and 3/4/26. During interview, the RN confirmed these dates did not include complete dialysis communication forms and that the facility failed to provide consistent and complete communication with the dialysis center for Resident R79.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that trauma-informed care was provided to a resident with PTSD. Review of the facility policy indicated that trauma-informed care was intended to guide staff in minimizing triggers and re-traumatization and to support individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Resident R153 was admitted to the facility and had an MDS dated 2/27/26 that listed PTSD, depression, and anxiety as active diagnoses. A psychiatric evaluation dated 2/24/26 stated that the resident’s PTSD symptoms remained at baseline. The resident’s care plan dated 9/9/25 included general mood-related focuses, but it did not identify PTSD or include any triggers or methods to avoid them. During an interview on 3/12/26 at 12:10 p.m., RN E15 confirmed that the care plan did not contain a trauma-informed care plan addressing PTSD or identifying potential triggers and prevention for re-traumatization. The report stated that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with PTSD for one of five residents reviewed.
Mechanical Lift Competency Deficiency
Penalty
Summary
The facility failed to ensure that nursing staff had the specific competencies and skill sets needed to use mechanical lifts for two nurse aides, E26 and E27. The facility’s NA job description stated that staff are to use appropriate lifting devices to ensure resident and staff safety, and the facility had 46 residents who utilized a Hoyer lift and Hoyer pad for transfers. However, the files for E26 and E27 did not include a competency on how to utilize a Hoyer lift or on the correct Hoyer pad and pad size for each resident, and the facility’s Mechanical Lift Competency Checklist did not include how to determine the proper Hoyer pad kind and size. Resident R55 had diagnoses including high blood pressure, depression, and Alzheimer’s disease, and physician orders directed that the resident be transferred with a Hoyer lift, assist of two, with no ambulation. During a transfer from wheelchair to bed using the Hoyer lift, E26 and E27 reported that the resident slid out of the lift and landed on her head. Nursing was notified, the resident was assessed, and she was sent to the hospital for evaluation. The DON stated that the aides used the Hoyer pad with the legs cut out, and the facility reviewed the scenario but could not determine what went wrong.
Failure to Ensure Understanding of Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that two residents had the capacity to understand the terms of a binding arbitration agreement and failed to ensure the agreement was explained to the resident and representative in a form and manner they could understand. Review of records showed Resident R18 was admitted with Crohn's disease, peripheral vascular disease, and unspecified intellectual disabilities, and the MDS dated 1/23/26 documented a BIMS score of 10, indicating moderate cognitive impairment. Despite this, the resident's binding arbitration agreement was signed on 7/16/25, and the record described the resident as having severe cognitive impairment at the time of the agreement. Resident R104 was admitted with dementia, depression, and anxiety, and the MDS dated 1/16/26 documented a BIMS score of 0, indicating severe impairment. The resident's binding arbitration agreement indicated the resident verbally agreed to the document on 7/29/25, also with severe cognitive impairment. During an interview on 3/11/26, the admission director confirmed the facility failed to ensure resident rights to make informed decisions and choices regarding the binding arbitration agreement and failed to ensure the agreement was explained to the resident and representative in a manner they understood.
Missing Hospice Documentation
Penalty
Summary
The facility failed to make certain that hospice documentation was maintained for two residents receiving hospice services. Facility policy stated that hospice services are provided under contractual arrangement and that complete details of the responsibilities of the facility and hospice agency are contained in the agreement on file. For one resident, the clinical record showed an order for hospice services, and the hospice communication binder contained a hospice certification and plan of care, a medication list, and a care plan; however, during interview, an LPN confirmed the record lacked a current hospice plan of care and an updated medication list, and that hospice documentation was not maintained. The resident’s MDS also reflected diagnoses of high blood pressure, depression, and Alzheimer’s disease. For a second resident, the clinical record showed hospice services were received and current physician orders indicated admission to an outside vendor’s hospice services. The hospice binder, however, did not include a current plan of care, and an RN confirmed this during interview. The DON later confirmed that the hospice communication binder for the first resident was not up to date and that the facility failed to make certain hospice documentation was maintained for the two residents reviewed for hospice services.
Expired Inspection Sticker on Resident Transport Vehicle
Penalty
Summary
The facility failed to make certain that one of its three vehicles used to transport residents to appointments was in safe operating condition because the vehicle had an expired inspection sticker displayed. A resident stated that one of the facility's vehicles used for resident transportation had an expired vehicle inspection sticker. During an observation in the facility parking lot, vehicle number one was found with an inspection sticker showing an expiration date of [DATE]. A van driver confirmed that the facility employs three drivers and uses three vehicles to provide daily transportation services for residents, and another van driver confirmed that vehicle number one had an expired inspection of [DATE]. The Nursing Home Administrator also confirmed that the facility failed to ensure that equipment was in safe operating condition.
Failure to Provide Required Annual Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that one of four sampled Nurse Aides, NA Employee E7, received the minimum 12 hours of annual in-service education required by facility policy. Review of the Staff Development Program policy dated 10/1/25 showed that Certified Nursing Assistants/Aides are to receive at least 12 hours of in-service per year, with annual training to include mandatory topics such as infection prevention and control, fire prevention and safety, accident prevention, disaster preparedness, confidentiality, resident psychosocial needs, restorative nursing, resident rights, privacy rights and dignity, abuse prevention and reporting, nutrition and hydration, hazardous materials, and ethical code of conduct. Review of NA Employee E7’s personnel file showed a hire date of 11/18/13, and review of the nurse aide training records showed that E7 did not receive 12 hours of in-service training from 1/1/25 through 12/31/25. The facility was unable to provide documented evidence that E7 had received the required yearly in-service training. During an interview on 3/11/26 at 1:58 p.m., Education Department RN Employee E6 confirmed that the facility failed to ensure NA Employee E7 received the required 12 hours of yearly in-service training.
Missing Required Resident Complaint and Agency Postings
Penalty
Summary
Required resident-facing postings were missing from areas accessible to all residents. During a tour of the facility and interview with the Nursing Home Administrator, surveyors reviewed the information posted for residents and found that it did not include contact information for Adult Protective Services, did not provide a complete address or email for the State Agency, did not include an address for the State Long-Term Care Ombudsman program, did not include an address or email for the Medicaid Fraud Unit, and did not include a statement that residents may file a complaint with the State Survey Agency. The Nursing Home Administrator confirmed these findings and acknowledged that the facility failed to have the required postings in accessible areas as required by 28 Pa. Code 201.14(a) and 201.18(b)(3).
Grievance Official Information Not Posted
Penalty
Summary
The facility failed to provide information on the grievance official throughout the facility as required. During a tour of the facility and interview on 3/13/26 at 10:50 a.m. with the Nursing Home Administrator, grievance boxes were observed but did not include the name of the grievance official, address, email, or phone number. The NHA confirmed that the facility did not have grievance official information accessible to all residents as required under 28 Pa. Code 201.29(a) resident rights.
Failure to Provide Palatable and Attractive Food at Lunch
Penalty
Summary
The facility failed to provide palatable, attractive, and appetizing food at a safe temperature during the lunch meal on 12/29/25. Multiple residents expressed dissatisfaction with the food, describing it as unappetizing, cold, lacking flavor, and generally of poor quality. Resident interviews revealed consistent complaints about the food's taste and appearance, with several residents stating that the quality had declined in recent months. A review of the facility menu indicated that turkey pot pie, honey glazed carrots, fruited gelatin, and beverages were scheduled for lunch, but residents reported the food was barely edible or not appetizing. During direct observation, the turkey pot pie served was found to be in a fluid, soup-like form, lacking the expected consistency and appearance. One resident's meal was missing key ingredients, containing only a single pea and no carrots. The Food Service Director acknowledged that the meal did not turn out well and attributed the poor quality to issues with a new food vendor and inconsistent cooking staff. The deficiency was confirmed by both resident feedback and staff admission, as well as direct observation of the meal served.
Failure to Prevent Elopement Due to Inadequate Supervision and Lapses in Safety Protocols
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as high risk for elopement, resulting in the resident leaving the facility without staff knowledge. The resident, who had a history of cognitive impairment, poor decision-making skills, and demonstrated exit-seeking behavior, was assessed as an elopement risk and had interventions in place, including placement on a secure unit with a wander guard and scheduled 15-minute checks. Despite these interventions, the resident was last seen in the dining room and was later found missing during medication rounds. Staff statements indicated that the resident was observed in the dining room and walking the unit, but there were gaps in supervision and incomplete documentation of required safety checks. The resident was able to exit the unit by accessing the elevator after learning the code, which was reportedly spoken aloud by staff. The resident then left the building and was located by police approximately 600 yards from the facility. Documentation revealed that the required 15-minute safety checks were incomplete or missing for several days, including the day of the elopement, and staff were unable to account for the resident during routine checks. The resident later stated that he was able to leave because he knew the elevator code and expressed a desire to leave the facility. Interviews with staff and review of facility records confirmed that the facility did not maintain adequate supervision or ensure the effectiveness of elopement prevention measures for this high-risk resident. The failure to consistently perform and document safety checks, as well as to secure the elevator code, directly contributed to the resident's ability to elope. This incident created an immediate jeopardy situation for the resident, as confirmed by the Director of Nursing and survey findings.
Removal Plan
- R3 was assessed for injury.
- Physician orders were reviewed, and plan of care was updated.
- R3's care plan was updated to include a change from Q 15-minute checks to 1:1 observation based on length of time needed to exit unit.
- Family and provider were notified.
- A root cause analysis was conducted.
- Maintenance changed elevator code.
- All stairwell doors and exterior doors were checked to ensure functionality with no issues identified.
- Education on facility elopement policy, notifying maintenance if a resident learns the elevator code, and making sure stairwell doors are closed and locked after use was implemented.
- QAPI meeting was held to review root cause analysis and elopement policy.
- Director of Nursing confirmed that R3 elopement risk assessment correctly identified him as an elopement risk and was up to date.
- Elopement risk assessments were reviewed and confirmed up to date and accurate for all residents.
- For residents assessed to be at risk for elopement, care plans were confirmed to include interventions to minimize risk of successful elopement.
- All staff were confirmed to have received elopement education.
- Director of Nursing will audit all admissions/readmissions to ensure elopement risk assessment is completed and residents at risk of elopement have interventions listed in their care plan to reduce the risk of successful elopement.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to ensure effective management and supervision for residents identified as high risk for elopement, resulting in an actual elopement event that created an immediate jeopardy situation. Review of job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) showed that both roles are responsible for ensuring compliance with federal, state, and local regulations, as well as maintaining the highest degree of quality care. However, based on facility and clinical records, as well as staff interviews, it was determined that the NHA and DON did not fulfill these responsibilities, specifically by not providing the required supervision for high-risk residents. This lapse led to a resident elopement, indicating a failure to provide care and treatment in accordance with professional standards of practice and facility policies.
Failure to Pay Vendors in a Timely Manner
Penalty
Summary
The facility failed to pay bills in a timely manner, resulting in significant outstanding balances to multiple vendors. Review of the Nursing Home Administrator's job description confirmed responsibility for managing the facility in accordance with all applicable regulations and for all financial transactions. Financial documents revealed that the facility was placed on a weekly payment plan with a staffing agency after accruing a debt of $3,829,128.60. The staffing agency suspended services due to non-payment, which were only reinstated after a payment was received. Additionally, the facility owed substantial amounts to both water and sewage vendors, with the water vendor reporting an outstanding balance of $274,465.77 and the sewage vendor $217,024.70. The water vendor had initiated court action to recover payments, and the sewage vendor reported having to send monthly reminders for overdue payments. The Nursing Home Administrator confirmed the facility's failure to remain current with these vendors and indicated that payment plans were being sought.
Failure to Employ Qualified Social Worker for Required Period
Penalty
Summary
The facility failed to employ a qualified full-time social worker for approximately 388 residents over a nine-day period. Documentation review showed that the previous social worker's last day was 8/29/25, and the new hire began on 8/6/25, but there was a gap in qualified coverage from 8/30/25 to 9/7/25. The new social worker's personnel file did not include evidence of a qualifying degree, as transcripts revealed a Bachelor of Arts in history with a minor in anthropology, which does not meet the requirements for a qualified social worker. The previous social worker returned to work on 9/8/25, but during the nine-day gap, the facility did not have a qualified social worker on staff as required by regulations.
Failure to Resolve Vendor Payment Deficiencies Through QAPI
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies related to the non-payment of essential service vendors, specifically water and sewage vendors. Despite having a policy that requires quarterly QAPI meetings to identify and address areas of non-compliance, and a plan of correction that included auditing and communication protocols for vendor payments, the facility did not maintain current payments to these vendors. Documentation and interviews revealed that outstanding invoices for water and sewage services remained unpaid, with significant amounts owed to both vendors. During the survey, vendor representatives confirmed that large sums were overdue, with the water vendor stating that court action had been initiated to recover payments and the sewage vendor reporting ongoing delays and the need for repeated reminders. The Nursing Home Administrator acknowledged the failure to remain current on these payments and confirmed that the QAPI program did not resolve the previously identified deficiencies. This ongoing issue has the potential to affect all residents in the facility.
Failure to Ensure Resident Rights in Admission and Transfer Processes
Penalty
Summary
The facility failed to ensure that residents with cognitive impairments or legal guardianship had their rights upheld during the admission and transfer processes. Specifically, one resident with a moderate cognitive impairment, as indicated by a BIMS score of 11 and diagnoses including traumatic brain injury and mood disorder, signed the admission notice agreement despite lacking the capacity to understand its terms. Staff interviews confirmed that this resident struggled to comprehend the billing process and did not have the capacity to understand the admission agreement. Another resident, who had a court-appointed guardian due to an intellectual disability and schizoaffective disorder, also signed admission paperwork instead of the guardian, contrary to legal requirements. Additionally, the facility did not provide residents or their representatives with a choice regarding transfer destinations for three residents. One resident with severe cognitive impairment and Alzheimer's disease was transferred to another facility without the representative being informed of options or being contacted by the original facility. Another resident with multiple chronic conditions was transferred without the representative being involved in the selection of the new facility. A third resident, with severe cognitive impairment and schizophrenia, was also transferred without the representative being informed or given a choice, and the representative only learned of the transfer from the receiving facility. These deficiencies were identified through review of facility policies, resident records, and staff and representative interviews. The findings indicate that the facility did not ensure informed consent or resident choice in key processes, particularly for residents with cognitive impairments or those under guardianship, as required by federal and state regulations.
Failure to Notify Resident Representatives of Transfers
Penalty
Summary
The facility failed to ensure that resident representatives were appropriately notified of decisions to transfer residents for seven out of nine residents reviewed. According to the facility's own policy, notification of the resident and their representative regarding transfers and the reasons for such transfers must be documented in the clinical record. However, clinical record reviews and interviews with resident representatives revealed that in multiple cases, representatives were not informed by the facility about the transfers. Instead, they learned of the transfers either from the residents themselves or from staff at the receiving facilities. Several residents involved had significant cognitive or mental health diagnoses, including schizoaffective disorder, bipolar disorder, dementia, Alzheimer's disease, and schizophrenia. BIMS scores for these residents ranged from cognitively intact to severely impaired, indicating varying levels of ability to understand and communicate about their care. Despite documentation in progress notes and social service notes stating that families were aware of the discharges, interviews with representatives consistently indicated a lack of direct communication from the facility regarding the transfers. The deficiency was identified through a combination of policy review, clinical record examination, and interviews with both staff and resident representatives. The findings showed a pattern where representatives were not given the opportunity to participate in or be informed about the transfer process, with some expressing confusion and concern about not being notified or consulted. This failure to notify was found to be in violation of state regulations regarding resident rights and facility management responsibilities.
Failure to Communicate Resident Information and Document Transfer Reasons
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to receiving health care providers and did not document the reasons for transfers to alternate health care providers for seven residents who experienced facility-initiated transfers. Facility policy requires notification of the resident and, if known, their family or representative, as well as documentation of the reason for transfer in the clinical record. However, reviews of the clinical records for these residents showed no evidence that such notifications or documentation occurred. For each of the seven residents involved, the clinical records lacked documentation that specific information was communicated to the receiving health care provider. This information should have included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and all necessary details to meet the resident's needs at the receiving facility. The records also failed to include the reasons for each resident's transfer. The residents affected had various diagnoses, including schizoaffective disorder, anxiety, insomnia, bipolar disorder, high blood pressure, dementia, Alzheimer's disease, anemia, hyperlipidemia, hypothyroidism, COPD, malnutrition, schizophrenia, low blood pressure, peripheral vascular disease, and chronic kidney disease. During an interview, the DON confirmed that the facility did not ensure the required communication and documentation for these transfers. The deficiency was identified through review of facility policy, clinical records, and staff interviews, and it was found to be in violation of 28 Pa. Code: 201.29 (a)(c.3)(2) regarding resident rights.
Failure to Accommodate Residents' Restroom Needs
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents whose shared bathroom had been inoperable for approximately one month. During an observation, caution tape was found around the commode in their bathroom, and staff interviews confirmed that the residents had been unable to use their own restroom for an extended period. Instead, they were required to use a restroom located on another nursing unit. Maintenance staff acknowledged not having addressed the issue in the past week, and the Director of Nursing confirmed that the residents were not offered a room move or other reasonable accommodations during this time.
Significant Medication Error Due to Double Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses of high blood pressure, dementia, and anxiety was administered a double dose of their morning medications. The incident happened after the resident requested their medications from an LPN, who, due to a lack of clear communication and documentation between nursing staff during a shift change, provided the medications without realizing they had already been administered by the previous nurse. The medications given twice included Aspirin, Centrum Silver, Isosorbide Mononitrate Extended Release, and Lisinopril-Hydrochlorothiazide. Following the double administration, the resident exhibited mild shortness of breath and hypotension, prompting a call to the physician and subsequent transfer to the emergency room. The facility's policy required medications to be administered as prescribed and documented immediately after administration. However, the LPN was unable to document the administration in the electronic medical record at the time and relied on verbal communication, which led to the oversight. The Director of Nursing confirmed that the facility failed to ensure residents are free from significant medication errors, as required by state regulations.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the potential for accidents to occur. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from preventable incidents.
Failure to Maintain Kitchen Sanitation and Proper Food Storage
Penalty
Summary
The facility failed to maintain proper cleanliness and sanitation in both the main kitchen and basement storage areas, as well as to properly date and store food products to prevent foodborne illness. Observations included mixing bowls and warming pans not being inverted, brown staining and standing water behind the hand washing station, paper debris and discarded gloves on the floor, and food items in the walk-in coolers and storage rooms that were either not labeled with dates or were past their expiration dates. Additional issues included caulking peeling from the ceiling in the spice storage room, streaking on the walls in the dry storage room, and packaging materials discarded on the floor. Further inspection of the basement kitchen storage areas revealed water dripping from the ceiling, puddles on the floor, crumbling ceiling material, and debris present. The basement freezer contained paper debris and food items that were not properly labeled. These findings were confirmed by the Dietary/Facility Manager and the Nursing Home Administrator during interviews, acknowledging the failure to maintain cleanliness, sanitation, and proper food storage practices as required by facility policy.
Failure to Pay Essential Service Bills in a Timely Manner
Penalty
Summary
The facility failed to pay outstanding bills to two vendors in a timely manner, as required by state regulations. Documentation provided by Vendor 1 and Vendor 2 showed significant unpaid balances, with Vendor 1's outstanding bill exceeding $200,000 and Vendor 2's bill accumulating to nearly half a million dollars. The vendors confirmed that there were no payment plans in place with the facility. The accounts payable ledgers provided by the facility corroborated these outstanding balances for both vendors. Vendor representatives indicated that the unpaid bills were for essential services, and one vendor was considering shutting down water services due to non-payment. Interviews with the Nursing Home Administrator (NHA) revealed a lack of direct involvement or oversight regarding the payment of these bills, with the NHA stating that the accounts payable office was responsible for handling payments. The NHA later acknowledged the failure to pay the vendors in a timely manner. The facility's failure to manage its financial obligations for essential services was found to be non-compliant with state licensure regulations, which require timely payment of bills necessary for resident health and safety.
Failure to Provide Appropriate Body Soap for Resident Care
Penalty
Summary
The facility failed to accommodate the body soap needs of four out of five residents, as evidenced by staff interviews, observations, and review of facility policy and records. The facility's policy requires providing necessary care and services to maintain residents' well-being, but staff reported that the facility stopped purchasing body soap for resident care. Instead, staff were instructed to use hand soap from the sink dispensers, which was confirmed by multiple nurse aides and housekeeping staff. Some staff members reported bringing in their own soap from home due to concerns about residents' already dry skin and the inappropriateness of using hand soap for bathing. Observations and interviews confirmed that the soap available in residents' rooms was labeled as Gentle Foam Soap, intended for hand cleansing, not for use as body wash. Central supply and housekeeping staff corroborated that the facility had discontinued purchasing individual bottles of body soap and was now using hand soap in resident care areas. The affected residents had various medical conditions, including high blood pressure, hemiparesis, hemiplegia, schizophrenia, stroke, COPD, chest pain, and urinary tract infection. The deficiency was cited under state regulations for responsibility of the licensee, resident care policies, and nursing services.
Failure to Maintain Safe, Clean, and Homelike Environment Across All Resident Areas
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for residents across all ten resident areas, as evidenced by multiple observations and staff confirmations. Surveyors observed obstructions such as a table and chair placed in front of an exit door, damaged flooring, holes in lounge floors, dented and scratched doors, and exposed metal in various locations. Additional findings included black marks on shower room floors, torn and peeling wallpaper and trim, broken blinds, and corroded surfaces with food debris and dried liquids. Several bathrooms and resident rooms had structural damage, such as peeling plaster, broken tiles, and water leakage, as well as dirty or stained privacy curtains. Interviews with staff, including LPNs, nurse aides, the Dietary/Facility Manager, and the Director of Nursing, confirmed the presence of these deficiencies. Residents were directly affected, as in the case where a resident reported that the air or heat did not work due to an unreachable outlet and that water leaked from a pipe behind broken tiles when the toilet was flushed. Housekeeping and maintenance services were found lacking, with staff noting that certain areas had not yet been cleaned or repaired. The observations and interviews demonstrated that the facility did not maintain a sanitary, orderly, and comfortable interior as required by facility policy and federal regulations. The issues were widespread, affecting all resident areas, and included both environmental hazards and failures in routine maintenance and cleaning. These deficiencies were confirmed by multiple staff members and management during the survey.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to five staff members, including nurse aides, an LPN, and an RN. Review of the facility assessment indicated that all employees were to receive mandatory education, including QAPI, through self-directed coursework, with completion tracked by the Director of Education. However, upon review of the education files for these staff members, there was no documentation of QAPI training present. During staff interviews, the Human Resource Director confirmed that these five staff members had not received the required QAPI training. The deficiency was identified through review of facility assessment documents, employee education files, and staff interviews, and was cited under state regulations regarding staff development, management, and the responsibility of the licensee.
Failure to Provide Privacy and Dignity in Restroom Facilities
Penalty
Summary
The facility failed to ensure resident privacy and dignity on the Second and Fifth Main Floors, as required by its Resident Rights policy. On the Second Floor, the men's restroom was observed to be missing a curtain for one of two bathroom stalls, compromising privacy. On the Fifth Floor, the main south patient's restroom lacked an appropriately sized curtain for the first stall and had no curtain at all for the fourth stall. These deficiencies were confirmed by staff interviews, including an RN, an LPN, and the Director of Nursing, who acknowledged the absence of privacy measures in these restrooms. No information was provided regarding the specific medical history or condition of the residents affected at the time of the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 647 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beaver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rochester Residence And Care Center | 2.7 mi | — | 109 | 2 |
| Providence Health & Rehab Center | 3 mi | ★★★★★ | 44 | 1 |
| Beaver Valley Rehabilitation And Healthcare Center | 6.6 mi | ★★★★★ | 29 | 1 |
| Concordia At Villa St Joseph | 7 mi | ★★★★★ | 16 | 0 |
| Beaver Healthcare And Rehabilitation Center | 7.1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.